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please read the article.

Physical Therapists and Direction
Of Mobilization/Manipulation:
An Educational Resource Paper





This white paper outlines the importance of upholding and pro-
moting compliance with the current American Physical Therapy
Association (APTA) position on Procedural Interventions Exclu-
sively Performed by Physical Therapists. This position impacts
all aspects of the physical therapy profession, including clinical
practice, regulation, licensure, and education. Historical and sup-
porting information related to Procedural Interventions Exclusively
Performed by Physical Therapists address the patient safety,
practice, education, and legislative/regulatory implications of this
position on the physical therapy profession.

Since 1998, APTA’s Guide to Physical Therapist Practice1 has
defined mobilization/manipulation as “a manual therapy technique
comprised of a continuum of skilled passive movements that are
applied at varying speeds and amplitudes, including a small ampli-
tude/high velocity therapeutic movement.” To achieve a common
language for describing this area of the physical therapist’s scope
of practice, the terms “thrust” and “nonthrust” manipulation were
established to replace the previous terms “manipulation” and “mo-
bilization,” respectively. The APTA Manipulation Education Manual
for Physical Therapist Professional Degree Programs further
defines thrust manipulation as a “high velocity, low amplitude
therapeutic movement within or at the end range of motion” and
nonthrust as manipulations that do not involve thrust.2 These defini-
tions emphasize that these procedures are applied on a continuum,
which requires ongoing examination and evaluation to determine
how to proceed along the continuum with modification of speed,
amplitude, and direction of forces for optimal clinical outcomes.

In response to longstanding concerns expressed by the American
Academy of Orthopaedic Manual Physical Therapists (AAOMPT)
that physical therapist assistants (PTAs) were receiving instruction
in and administering mobilization/manipulation, a skill set requiring
ongoing examination and evaluation, AAOMPT adopted the follow-
ing positions at the 1998 AAOMPT membership business meeting:

1. Any joint manipulation/mobilization techniques into a restricted
or painful range should be performed by the physical therapist
and not delegated to supportive personnel including physical
therapist assistants.

2. The AAOMPT is opposed to the teaching of joint manipulation/
mobilization to all supportive personnel including physical
therapist assistants.

The AAOMPT leadership collaborated with the Orthopaedic

Section and APTA Board of Directors in bringing similar motions
to the APTA House of Delegates. As a result, the APTA House of
Delegates (House) heard discussion in 1999 and in 2000 passed the
position statement: Procedural Interventions Exclusively Per-
formed by Physical Therapists (HOD P06-00-30-36),3 which states
the following (emphasis added):

The physical therapist’s scope of practice as defined by the Ameri-
can Physical Therapy Association Guide to Physical Therapist
Practice includes interventions performed by physical therapists.
These interventions include procedures performed exclusively
by physical therapists and selected interventions that can be
performed by the physical therapist assistant under the direction
and supervision of the physical therapist.

Interventions that require immediate and continuous examination
and evaluation throughout the intervention are performed exclusively
by the physical therapist. Such procedural interventions within the
scope of physical therapist practice that are performed exclusively
by the physical therapist include, but are not limited to,

• spinal and peripheral joint mobilization/manipulation, which
are components of manual therapy, and

• sharp selective debridement, which is a component of wound

The support statement for this position presented to the House
stated: “the Association should delineate those interventions
which, due to their clinical complexity and the sophistication
of judgment required to perform them, precludes delegation to
paraprofessionals or others. This position is consistent with the
House of Delegate’s endorsed Guide to Physical Therapist Practice
and A Normative Model of Physical Therapist Education.”

This position statement did not represent a change in philosophy
for the association.4 APTA policies and positions have long
maintained that the physical therapist assistant’s scope of work
did not include examination, evaluation, diagnosis, and prognosis.
Those elements of practice are to be performed exclusively by the
physical therapist.4,5,6,7 The purpose of the position was to more
clearly specify which interventions should never be directed to the
physical therapist assistant due to their inherent requirements for
skill and ongoing clinical decision making.


In 2002, in collaboration between AAOMPT, the Orthopaedic
Section, and the APTA Board of Directors, the House adopted
a position statement addressing clinical continuing education,
Clinical Continuing Education for Individuals Other Than Physical
Therapists and Physical Therapist Assistants.8

Physical therapist assistants may participate in continuing
education that includes and teaches subject matter and
interventions that differ from the description of entry-level
skills as described in A Normative Model of Physical Therapist
Assistant Education. Physical therapist assistants may use the
interventions taught in continuing education only as consistent
with the American Physical Therapy Association [policies,
positions, guidelines, standards, and the Code of Ethics] and
under the direction and supervision of the physical therapist.

During the 2005 AAOMPT Business meeting, AAOMPT member-
ship voted to adopt the APTA House positions on delegation and
continuing education. These positions have remained in place
within AAOMPT and APTA for over 10 years to enhance patient
safety and treatment effectiveness.

There are also legislative and regulatory reasons for these
positions that cannot be underestimated. For example, health
professions such as chiropractic that would like to limit physical
therapists’ scope of practice in mobilization/manipulation can
bolster their argument by pointing out that physical therapists may
potentially instruct and direct skilled procedures to supportive
personnel. APTA has been able to argue successfully in legislative
and regulatory battles with chiropractic that physical therapists
have the education and training in professional physical therapist
education to effectively and safely provide mobilization/manipula-
tion. It is easy to demonstrate that the master of physical therapy
(MPT) and doctor of physical therapy (DPT) degrees compare
favorably to the doctor of chiropractic (DC) degree in time, scope,
and content to effectively train manual therapy practitioners.
Conversely, PTA education results in a technical degree and is not
comparable to MPT, DPT, or DC education. Acting outside this posi-
tion not only magnifies liability for the physical therapist but also
places the physical therapist profession at risk of being challenged
or of losing manipulation as part of the physical therapist scope of
practice when physical therapy is criticized in legislative hearings
for delegating mobilization/manipulation.

In summary, these consensus-based positions provide important
clarity relevant to best clinical practice including patient safety,
education, and regulatory and legislative arenas. These positions
clarify the practice competency and latitude within the scope of
practice for the physical therapist and constraints within the scope
of work that can be directed to the PTA.

Immediate and Continuous Examination and Evaluation
Procedural Interventions Exclusively Performed by Physical
Therapists is based on the principle that “immediate and continu-
ous examination and evaluation,” critical components of clinical
reasoning, are inherent to the effective and safe provision of joint
mobilization/manipulation. It is understood that the implementation
of these procedures may produce new findings that must be evalu-
ated simultaneously as the interventions are implemented. Hence,
examination, evaluation, clinical reasoning, and intervention are
continuous and immediate.

Although many physical therapy tests and measures as well as
interventions are performed at the body systems and functions,
activity, and participation levels, there are elements of selected
physical therapy procedures that require careful evaluation of
tissue/organ and patient response. For these interventions, body
systems and functions response usually are qualitatively measured
by observation or palpation, applied clinical cues clinicians use
as decision points to continue or adjust the treatment. The data
gathered through the observations or palpations often are supple-
mented with the patient’s subjective reports.

In some physical therapy interventions, the treatment can be
divided into distinct phases, gathering data on new findings
produced during provision of the intervention, evaluating the data,
and using clinical decision making to determine the appropriate
action of continuing, reducing, or progressing further intervention.
PTAs, working under the direction and supervision of a physical
therapist, are generally expected to respond to any negative
patient responses immediately to ensure patient safety. In contrast,
PTAs generally are expected to continue or modify treatment in the
presence of a non-negative response to treatment only within the
boundaries established in advance by the physical therapist.

However, joint mobilization/manipulation is an example of an
intervention that does not easily lend itself to being segmented
into distinct sequential phases of evaluation and implementa-
tion. Clinical judgments about the amount of force to apply to
create or progress an arthrokinematic change cannot be made
on a “stop-evaluate-decide-proceed” linear time sequence. The
implementation of the procedure, by its very nature, produces new
findings that must be evaluated simultaneously as the intervention
is implemented. Examination, evaluation, intervention, and clinical
decision making are inseparable in the performance of mobiliza-

The essential arthrokinematic motion applied to the joint in
mobilization/manipulation is not under voluntary control of the
patient, and the practitioner must produce this motion through
skilled manual techniques.9,10 This skill requires a detailed under-
standing of joint surface anatomy and kinesiology and a continu-
ous use of examination with clinical decision making to modulate


the technique throughout the treatment session.9,11 The negative
responses to application of mobilization/manipulation techniques
may include but are not be limited to worsening and/or peripher-
alization of symptoms, tissue damage, promotion of inflammation
leading to chronic pain and/or proliferation of scar tissue, spinal or
joint instability, and neurovascular compromise. Failure to properly
evaluate responses during the course of examination or intervention
could result in adverse responses from the intervention, ranging
from increased pain and deformity, to loss of function, to death.12-19

Since the safe application of mobilization/manipulation requires the
practitioner to apply an advanced understanding of arthrokinema-
tic principles simultaneously with ongoing examination, evaluation,
and clinical decision making during the intervention, the PTA would
not be an appropriate provider. In 2007, the APTA’s Departments
of Education, Accreditation, and Practice produced a “Problem
Solving Algorithm Utilized by PTAs in Patient/Client Intervention.”
The application of mobilization (nonthrust manipulation) requires
dedicated consistent monitoring and evaluation of the patient/
client response. The algorithm clearly indicates that evaluation is
not among the controlling assumptions of PTA practice.20 This is in
contrast to osteokinematic range-of-motion interventions in which
patients have more voluntary control and are within the PTAs’
scope of work.

Efficacy and Effectiveness of Mobilization/Manipulation
Published peer-reviewed research on the efficacy and effective-
ness of mobilization/manipulation interventions provided by
physical therapists has repeatedly demonstrated the effectiveness
of such interventions for a variety of conditions and regions of the
body.21-30 However, there are no research studies available that
address the efficacy of the practice of mobilization/manipulation
provided by PTAs. Therefore, it cannot be assumed that a similar
level of effectiveness of manual therapy interventions can be
produced when the mobilization/manipulation is directed to PTAs.

Legal and Safety Implications of the Current Position
At least 35 state practice acts are silent on the issue of direction
of mobilization/manipulation to the PTA. Even so, there is a liability
risk when physical therapists choose to practice contrary to the
current APTA position on delegation of mobilization/manipulation
procedures to PTAs. According to Welk, “A clinically inappropriate
decision to direct physical therapy services increases the PT’s risk
of professional liability claim. It is important to realize that while
APTA policies may in fact require more than the absolute legal
requirements of state or federal law, a court still may look to APTA
policy in a professional liability action to determine if a physical
therapist acted within an acceptable standard of care in delegat-
ing physical therapy services.”31

If injury occurs at the hands of a PTA performing mobilization/ma-
nipulation procedures in these states, the standard of care may be
determined by APTA policy. The current policy will make it difficult

to defend the practice of a PT who directed a PTA to perform these
procedures. According to Welk, “In the unfortunate event that a
professional liability claim arises that includes issues of delega-
tion, the supervising PT will be required to support the delegation
decision. This can put the PT in a difficult if not impossible position
if the delegation decision was not in compliance with the state
practice act and/or APTA policies, or was inconsistent with what a
reasonable PT would have done under similar circumstances”31

The analysis also indicates risk for injury when a PTA performs
mobilization/manipulation techniques. It reports that the top 3
severities by allegation claims related to PTAs 2001–2010 were:

1. Improper use of equipment

2. Improper management over the course of treatment

3. Improper performance of manual therapy 32

In addition, CNA found that failure to monitor the patient during
treatment accounted for the highest percentage of PTA claim.32
To protect the public, state physical therapy licensing boards
should consider adopting regulations consistent with the APTA
position on Procedural Interventions Exclusively Performed by
Physical Therapists.

At the 2006 APTA House, the Texas Chapter delegation proposed
RC-12, which would have rescinded Procedural Interventions Ex-
clusively Performed by Physical Therapists. At the motion’s presen-
tation to the 2006 House, the parliamentary procedure “object to
consideration” was made and sustained by more than the 2/3 votes
required to sustain the motion. This was a strong endorsement by
the 2006 APTA House in support of the current position.

In spring 2012, the Federation of State Boards of Physical Therapy
(FSBPT) published the results of its recent PT and PTA practice
analyses.33 FSBPT conducts surveys every 5 years to develop the
blueprints for both the PT and PTA national examinations. Of note
were 2 items in the manual therapy intervention category that had
previously not been included on the PTA exam but did meet the
threshold in this survey administration:

• Item 62, Perform peripheral mobilization/manipulation (non-thrust)
• Item 64, Perform spinal mobilization/manipulation (non-thrust)

An item equivalent to item 62 reached threshold in the 2006 survey,
but the FSBPT exam policy committee decided against recom-
mending that this content be added to the exam, a determination
the FSBPT Board accepted. In the 2011 survey process, the policy
committee recommended that these items appear on the exam,
resulting in a decision by the FSBPT Board to include them on the
content outline.


The item numbers related to peripheral and spinal mobilization/ma-
nipulation reached the critical threshold of 25% of the respondents
indicating they performed the activity, and so these items are now
eligible to appear on the exam. Of additional note is the frequency
with which these respondents reported performing these items.
The frequency reported for Item 62 (peripheral) is 1.26 (1 = “a few
times a year” and 2 = “once a month”). The frequency reported for
Item 64 (spine) is 0.78 (0 = “never” and 1 = “a few times a year”).33

On September 6, 2012, the Commission on Accreditation of
Physical Therapy Education (CAPTE), the national accreditation
organization for physical therapist and physical therapist assistant
education programs, released a statement regarding the inclusion
of mobilization in PTA curricula, which was amended on November
7, 2012, to read (emphasis added):

PTA Education and Peripheral Joint Mobilization

As the preferred extender of physical therapy services, physi-
cal therapist assistants (PTAs) are educated and licensed
to deliver physical therapy interventions within the plan of
care designed by the physical therapist (PT). To safely and
effectively fulfill this role, the PTA must possess knowledge
of the rationale for all components of the treatment plan
as directed by the physical therapist. The Commission on
Accreditation in Physical Therapy Education (CAPTE) believes
that the knowledge of the entry-level PTA should include the
rationale for manual therapy procedures such as soft tissue
and non-thrust joint mobilization techniques. Furthermore, the
Commission believes that it is not inappropriate to train PTAs
to perform soft tissue mobilization or to manually assist the
PT in the delivery of peripheral joint mobilization procedures
(ie, assist with patient positioning, stabilization, or grade 1-2
movements). CAPTE does not support the inclusion of educa-
tional objectives or learning experiences in the entry-level PTA
curriculum that are intended to prepare the PTA to perform
grades 3-5 (thrust) procedures.

CAPTE is responsible for ensuring that all accredited programs
meet a minimum set of educational standards in physical therapy.
CAPTE’s recognition agencies (the US Department of Education
and the Council for Higher Education Accreditation) require that
all accrediting agencies have independent authority, free from in-
terference by sponsoring organizations, for their decisions related
to standards and to the accreditation status of programs. As such,
APTA did not have a role in the decision by CAPTE on this issue.
CAPTE’s statement is about curricular content only; it does not
address the appropriateness of the PT in directing and supervis-
ing the PTA in the application of such techniques. Further, it does
not require that physical therapist assistant education programs
include this content; it does, however, open programs that include
the content to increased scrutiny by CAPTE regarding the quality of
relevant student outcomes.

Prior to the September 2012 statement, CAPTE documents were
quite clear and consistent with APTA policy in that only physical
therapist training included didactic, psychomotor, and clinical
training in thrust and nonthrust mobilization/manipulation for the
spine and extremities. The design and implementation of physical
therapist professional education curriculum are supported by both
A Normative Model for Physical Therapist Professional Education
and the CAPTE Evaluative Criteria for Accreditation of Education
Programs for the Preparation of Physical Therapists. Both the
normative model and CAPTE evaluative criteria are specific that
both thrust and nonthrust manipulation techniques are taught
exclusively in physical therapist professional education programs 34,35
A Normative Model for Physical Therapist Assistant Education and
the CAPTE evaluative criteria for PTA education exclude the exami-
nation and evaluation skills and the interventional skills required
for safe and effective implementation of mobilization/manipulation.

In response to the above FSBPT and CAPTE actions, APTA Presi-
dent Paul Rockar provided the following statement in a September
18, 2012, letter to APTA component leaders: “As the organization
that represents physical therapists, physical therapist assistants,
and students, APTA creates and communicates professional
standards to which members should aspire. The current standard
for the intervention of manual therapy is in part expressed in the
APTA House of Delegates position on the issue of delegation of
joint mobilization/manipulation to PTAs, which remains in place
and unaffected … .” As noted in Rockar’s letter, APTA holds firm to
its support of the Position on Procedural Interventions Exclusively
Performed by Physical Therapists.

At its April 2013 meeting, CAPTE rescinded its statement PTA
Education and Peripheral Joint Mobilization. At the same meeting
CAPTE adopted a new position paper titled Expectations for the
Education of Physical Therapists and Physical Therapist Assistants
Regarding Direction and Supervision,36 which states the following
(emphasis added):

CAPTE expects educational programs to prepare PT students
to determine those components of interventions that may be
directed to the physical therapist assistant. These consider-
ations should include the level of skill and training required
to perform the procedure, the level of experience/advanced
competency of the individual PTA, the practice setting in
which the procedure is performed, and the type of monitoring
needed to accurately assess the patient’s response to the
intervention. In addition, acuity and complexity of the patient’s
condition and other clinical factors should be considered
when directing PTAs to safely and competently perform any
intervention. CAPTE also expects PTA educational programs
to prepare PTA students to recognize components of interven-
tions that are beyond their scope of work. (see PTA Criteria through


Likewise, CAPTE expects education programs for the PTA
to select the appropriate depth and breadth of knowledge
and skill needed to perform interventions that are consistent
with the PTA’s responsibilities. These skills not only include
specific intervention procedures but also the data collection
skills needed to monitor and assess a patient’s response to
an intervention. These data collection skills are outlined in
the evaluative criteria. Regardless of the relative simplicity or
complexity of the procedure itself, CAPTE also believes that
those interventions which require more extensive founda-
tional knowledge, manual skill, and/or complex monitoring
than a PTA is educated to provide should only be performed
by the physical therapist.

This white paper provides an historical overview and clear ratio-
nale for upholding and promoting the APTA position on Procedural
Interventions Exclusively Performed by Physical Therapists (HOD
P06-00-30-36). This issue has an impact on all aspects of the
physical therapy profession including clinical practice, educa-
tion, patient safety, and regulatory and legislative arenas. APTA
has concluded that, based on education, efficacy, and safety,
it is inappropriate for a physical therapist to direct the manual
therapy procedures of mobilization/manipulation to the PTA under
any circumstances. Further, beyond the specific interventions of
mobilization/manipulation, any procedure within physical therapist
practice that requires immediate and continuous examination and
evaluation throughout the intervention should not be directed to
the PTA.

As the principal membership organization representing and
promoting the profession of physical therapy,37 APTA encourages
state licensing boards to establish rules, regulations , or position
statements congruent with the position on Procedural Interven-
tions Exclusively Performed by Physical Therapists.

1. Guide to Physical Therapist Practice. Revised 2nd ed. Alexandria, VA: American Physical

Therapy Association; 2003.
2. APTA Manipulation Education Manual for Physical Therapist Professional Degree

Programs. Alexandria, VA: APTA Manipulation Task Force; 2004.
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Therapists. (HOD P06-00-30-36.) Alexandria, VA: American Physical Therapy Association; 2000.
4. APTA House of Delegates. Briefing Paper RC 12-06-1. Alexandria, VA: American Physical

Therapy Association; 2006.
5. APTA House of Delegates. Direction and Supervision of the Physical Therapist Assistant.

HOD P06-05-18-26. Alexandria, VA: American Physical Therapy Association; 2005.
6. APTA House of Delegates. Continuing Education for the Physical Therapist Assistant. HOD

P06-01-22-23. Alexandria, VA: American Physical Therapy Association; 2001.
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8. APTA House of Delegates. Clinical Continuing Education for Individuals Other Than Physical
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9. Maitland GD. Peripheral Manipulation. London: Butterworth; 1984.
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Olaf Norlis Bokhandel; 1964.

11. Olson KA. Manual Physical Therapy of the Spine. St Louis, MO: Saunders, Elsevier; 2009.
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reactions to chiropractic care in the UCLA neck pain study. Spine. 2005;30(13):1477-1484.
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14. DiFabio RP. Manipulation of the cervical spine: risks and benefits. Phys Ther. 1999;79(1):50-65.
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17. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of
the cervical spine: a systematic review of the literature. Spine. 1996;21:1746-1760.

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19. Danish Institute for Health Technology Assessment. Low Back Pain: Frequency,
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Technology Assessment (HTA) Database; 1999.

20. A Normative Model of Physical Therapist Assistant Education: Version 2007. Alexandria, VA:
American Physical Therapy Association; 2007.

21. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical
therapy for patients with shoulder impingement syndrome. JOSPT. 2000;30(3):126-137.

22. Bergman GJ, Winters J, Croesier KH, Pool JM, Jong B, et al. Manipulative therapy in addi-
tion to usual medical care for patients with shoulder dysfunction and pain: a randomized,
controlled trial. Ann Intern Med. 141(6):432-9; 2004.

23. Cleland JA, Fritz JM, Kulig K, Davenport TE, et al. Comparison of the effectiveness of three
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